The harsh realities of life have smashed many ideas, aspirations and ambitions of modern human beings. Thus, the individual to-day is constantly experiencing severe threat while making struggles for existence.

This leads to continuous frustration and by the by, frustration tolerance is also decreasing. People have become more intolerant and impatient. Rapid and sudden changes in the way of living and incapability to adapt with these changes have led to increase in the incidence of depression and also in the number of suicide attempts.

Mania and, depression come under affective disorders according to DSM III classification which is still in a draft stage. According to the classification of affective psychoses by DSM II Manic Depressive Psychoses is considered to be the most common as well as important mental disorder.

Manic Depressive Psychoses:

The term manic depressive psychoses were introduced by Kraepelin (1911) to characterize disorders of affect, either of elation or of depression. It is mainly a disorder of affect i.e. disorder in the emotional aspect of the person for which no physiological pathology has been noticed while schizophrenia is primarily a disorder of thought. Manic depressive psychoses is also called cycloid psychoses when it is characterized by periods of excitement and depression alternatively.

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Farlet (1884) recognised for the first time a cluster of symptoms and named them Manco, Melancholia. Fartett’s junior stated that this type of disorder is generally hereditary in nature. Falret and Baillanger described mania and depression as two independent diseases in the same organism. Kahlbaum (1882) emphasised that the phases Mania and depression or melancholia are not two separate types of mental disorder but as two stages occurring in the same disease.

Kraepelin (1896) made a further contribution to Manic depressive psychoses by viewing that periodic and circular insanity, simple mania melancholia and a number of cases of confusion and delirium also come under the affective disorder.

He opined that all these conditions represented a single morbid process and the different phases might succeed and replace one another. In the same patient Mania and melancholia might go in a circular way. However, as reported by Shanmugam (1981) “In the revised version of DSM-III which is at present in a draft form, only three categories are proposed. They are manic disorder, depressive disorder (both called unipolar affective disorder), and bipolar affective disorder.

The last named covers the alternative episodes of mania and depression. Stress, which was once considered as an important differentiating factor has been omitted; the neurotic-psychotic distinction and the category involutional melancholia have been discarded.”

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Thus, on the basis of the classification by DSM III Manic depressive psychoses may be classified into three subtypes.

1. Manic type. The characteristic feature of this type is excessive elation.

2. Depressive type. It is mainly characterised by severe depression.

3. Circular or mixed type. The circular type is characterised by alternated elation and depression.

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Manic depressive psychoses are quite a common affective disorder. This is supported by the report of Duke and Nowicki (1970) that 70,000 Manic depressive people were admitted to psychiatric admissions during that year, women patients outnumber men by a ratio of 2 to 1 in this disorder.

Duke reports that while schizophrenia is more commonly found in the lower classes, affective psychoses are more commonly found among the upper strata of the society. Again reports show that 58 per cent of the cases of the manic form of affective disturbances occur in young adults between ages of 20 and 35.

Manic depressive psychoses may be of two types, unipolar and bipolar. In unipolar psychoses cither manic symptoms or depressive symptoms are found. In bipolar psychoses mania and depression may occur in a circular form.

1. Manic type:

A manic patient is terribly optimistic, high in spirits and full of life. There is general excitement and the individual is full of activity and thus excessively mobile. The general symptoms of the manic stages are predominant emotional m6od, feeling of high optimism, and speeding up of thought process, excessive psychomotor activity. He lacks the capacity to concentrate, judgment is impaired and delusions of grandeur are commonly found.

The symptoms of the manic stage can be classified under the following heads:

(a) Excessive psychomotor activity:

Patients suffering from mania will like to do some kind of activity for say 20 hours in a day. They cannot sleep, nor can they relax. Any thought that occurs in their mind is immediately transformed to work. They cannot stick to a particular work or job.

They usually hastily change from one thought or task to another without completing the first one. Suppose for instance, he is working out Math or doing carpentry; immediately the idea of reading a book or playing a musical instrument may come to his mind. Thus, they start different types of work, but complete nothing. There is in fact, dramatic increase in gesturing, grimicking and general movement.

When admitted for hospitalization, sometimes they attempt to kiss the doctor, nurse or sing or dance here and there and make lots of noises. Sometimes they even try to stop the doctor or the nurse. Though they spend a lot of energy by this they are never seen fatigued.

(b) Flight of ideas:

Being overflowed with various types of ideas and thoughts the patient becomes inattentive and there is rapid shift of attention. As the train of ideas and thoughts come simultaneously they lack concentration power. Because of the distortion of thought process incomplete sentences are uttered and words are repeated.

(c) Emotional reactions:

The manic patients are extremely jolly, happy go lucky, active and joyful. They feel as if they are in bed of roses; in the peak of their name and fame. They do not hesitate to be vulgarly dressed, use obscene words. They are often aggressive. If they are slightly teased, insulted or not allowed to fulfill their wish, they become very obstinate, aggressive and violent. Often they argue and assert. But in spite of their anti-qualities people can like them because of their jolly nature. Miscellaneous Symptoms

Irritability, lack of insight, suspicion, delusions and hallucinations are present to some extent though delusions are short lived. Perception is erroneous and careless. Due to poor attention and distraction, memory difficulties are found.

Due to excessive excitement all the time, the patient loses his appetite. Their faulty judgment arises out of exaggerated optimism and excessive self- confidence. Though such patients realize that they are hyper active and quite excited all the time, they do not agree with the fact that they are psychotic and abnormal. They on the contrary, take it for granted that the doctor and the nurse are abnormal and not they. They consider their hospitalization as unnecessary and useless.

Manic reactions may be divided into 3 types:

1. Hypo Mania

2. Acute Mania

3. Delirious Mania.

These three types of reactions have the common symptoms discussed above. However, they only vary in the degree of excitement. In fact, there is no clear-cut difference between these stages.

1. Hypo mania:

It is the mildest variety and the least severe type characterised by mild form of manic reaction where the person does not seem to be out of control, but appears to be in a jolly mood. Cohen (1975) reports an elevated mood a pressured speech pattern in which words come out faster than the person can say them and an increased motor activity. However, the talk is never coherent

Elation and flight of ideas are found only in a moderate degree and are not greatly developed.

The patient feels extremely happy, has strong confidence in himself. He feels that he can do everything better than anybody else. However, he realizes his position in the society, and does not behave in a way that would clash himself with his fellow members in the society.

He shows egoism and monopolises in discussion, gives dogmatic views, shifts from one topic to another all of a sudden and shows flight of ideas when reasoned with. He is intolerant of criticism, becomes sarcastic and rude.

He may over indulge in sex and drink. He is sometimes arrogant and complains against officers, quarrels with them. The most striking symptom of a hypo-maniac is restlessness. He is extremely mobile. However, there is no clouding of consciousness. His idea of time, place and person is correct and there is no evidence of delusion and hallucination. His talk is coherent and his memory is intact.

According to Cohen (1975) “he talks easily, winningly, humorously and he talks and talks and talks. He is warm, then friendly and then uninvitedly intimate and unwelcomely personal…………….. He is constantly on the go and never seems to tire. Only as one stays with him, does one become aware of his distractibility, of impatience and intolerance, when his wish is not. Immediately gratified, of impulsive and ill considered actions of unseemingly self indulgence and of blind disregard of patent difficulties.”

2. Acute mania:

In this stage, without any previous hypomanic stage, all of a sudden acute excitement takes place. The elation, flight of ideas and over activity are more pronounced and intense in the acute mania stage in comparison to the hypomania stage. There is also some clouding of consciousness with disorientation and great impulsiveness.

Thus Duke and Nowicki (1979) have rightly viewed, “In acute mania, the characteristics of hypomania are present but to a greater degree. The mood disturbance is usually very apparent to others. The acute maniac may pun wisely, tease, make blasphenous comments, sing insane songs and move about widely “.

“The person with acute mania does not seem to care about the rights of others and may read violently to those who interfere. Frequently ideas pour forth in a torrent, with hallucinations and delusions being freely communicated”.

The acute mania has a sense of superiority and he orders everybody. Though he is quite gay and merry, periods of irritability and anger are frequent. The patient becomes over aggressive at times.

There is tremendous flight of ideas which may subsequently lead to incoherence. Hallucinations though may be present occasionally, are transitory in nature. Disturbance in sleep may be one of the important symptoms.

The acute mania is very restless and mobile and cannot sit at a particular place for a while. His mood is usually elated. He may be singing, dancing and giving humorous speeches. Misidentification is well evident. Language is full of slangs and talk is incoherent. The acute maniac is not normally clearly oriented of time and environment Attention is distracted. He pays attention to whatever he sees and comments upon it. Insight and judgment are also impaired to some extent.

3. Delirious mania:

Delirious mania was first described by Luther Bell (1949) and so is known as Bell’s mania. It is the extreme stage. It may either occur after one has passed through hypomania or acute mania or it may occur independent of these two stages.

In addition to the presence of most of the manic symptoms in an extreme degree, some additional symptoms are found in these stages. They are total loss of contact with reality, rampant auditory and visual hallucination and delusions. The patient has also frequent difficulty in controlling bladder and bowel functions.

They are totally unconcerned about their surroundings and it is quite difficult to deal with such patients. They are over energetic and over talkative. They are careless about their personal habits and use obscene language very often.

In the delirious stage, the patient is so excited, that he can only be restrained by a powerful hypnotic state. They are extremely suspicious and never cooperate with treatment. The strangest fact is that, they never realize that they are ill and on the contrary blame the doctor for treating them.

2. Depressive type:

Depression is the antithesis of mania. While the manic stage is characterised by elation, the depressive stage is in the opposite end of the feeling continuum. Patients with depressive mood show loss of energy and interest, guilt feeling, difficulty in concentration and loss of appetite. Thoughts of death and suicide travel their mind very often as they consider their life to be meaningless and useless.

Kraepelin also described a type of depression that begun after menopause in women and during late adulthood in men which is known as “Involutional Melancholia”. Unipolar depression is found approximately 20 per cent in women and 10 per cent in men. The lifetime expectancy of developing bipolar disorder is about 1 per cent in both men and women. Usually 20 to 25 per cent of the patients having major depression receive treatment.

It has been observed that unipolar depression prevalency is greater in women compared to men because of several factors. Trauma of childbirth and related factors, helplessness due to social conditions, hormonal efforts, greater stress due to disadvantaged socio cultural conditions, attitude of society towards women in general and oppression by the society are some of the major reasons of such unipolar depression in men. The fact that women cannot express their frustrations, emotions and hostility overtly like men leads to greater suppression and repression and consequently more depression.

The disease onsets in 50 per cent of the patients between the age of 20—50 years. Though race does not appear to have any specific effect on unipolar disorder, marital status has. Unipolar depression by and large is seen more in divorced or reparated persons and persons not having any close relationship. There seems to be no close relationship between social class and unipolar depression.

The patient is silent and morse and only thinks of death. He has guilty feelings about his past deeds and is usually unsuccessful in achieving a goal. Often suicidal thoughts appear in his mind and it is the most important symptom.

The type of mental disorder most likely to be associated with suicide is depression of the anxious agitated type characterised by hypo condriacal bodily delusions and the futility of existence. The psychotic depression is also characterised by obsession, delusions of persecution and auditory hallucination of self accusing guilt. Extremely depressed moods, mental and physical slowness are other common symptoms.

According to Duke, in some other cases, uneasiness; apprehension and agitation may be found. Symptoms of depression can be rated according to various clinical scales such as that prepared by Zung (1965).

According to the degree of severity the depressive stage can also be classified into 3 types.

1. Simple depression

2. Acute depression

3. Depressive stuper.

Difficulty in thinking, depression and psychomotor retardation are the common symptoms in these categories. Besides, delusions, hallucinations, persecutory characteristics and irritability etc. may be added. The depression however is not accompanied by anxiety.

The chief symptoms of the depressive stage can be described in the following manner.

(a) Inactivity:

There is absence of initiative, energy and eagerness to do anything. The patient lacks will power and strength. So the patient remains in bed for a longer period. The deterioration is so aggravated that he requires somebody to help him to get up. The person becomes a complete misfit and is unable to go anywhere or do anything. He withdraws himself completely from the outside world and likes to pass his time quietly, alone. He speaks very less and gives his answer to any question in a word or two.

The depressive patient often complains of paralysis of thought and inability to concentrate. Memory is lost, thought process is disorganised. Originality and self expression is destroyed.

(b) Emotional reactions:

So far as the emotional reaction of the. depressive patient is concerned he is always found to be gloomy and miserable. They assume life to be so hopeful and miserable, that sometimes they decide to get rid of this so called nasty world by committing suicide and some of them actually attempt it. They are always gloomy. So joy and humour have no meaning to them.

(c) Imsomnia:

Sleeplessness is usually found in a depressive patient. The patient complains about bad digestion, ill health etc.

(d) Insight:

Depressive patients realize that they are mentally sick and often voluntarily seek treatment.

(e) Degree of depression:

It ranges from mild cases to stupor conditions. The patient sometimes is so much depressed that he feels that his madness cannot be cured.

1. Simple depression:

It is mildest form of psychotic depression. Its most important characteristic is general loss of interest for mental and physical activity. The level of activity and functions of a simple depressive patient slows down to the extent of finding difficulty in doing simplest works like eating.

Social interaction and conversation is at the minimum level. For instance, he answers in monosyllables like Yes, No, Good, Right etc. This he speaks in a low voice. However, in a simple depressive the thinking process is more or less logical and coherent and hallucination and delusions are rare.

There is no real clouding of consciousness or actual disorientation. But it is different from normal depression in that the normal people experiencing depression return to the normal emotional state only after a few days and they are quite aware of the cause of their depression.

Normal depression may not relapse again. But simple depression is not connected with any real incident and its origin the victim cannot explain. Moreover, it increases in intensity gradually. The psychomotor activity of the simple type is retarded. He is very passive, lazy and looses interest in the entire environment. He has to be assisted in his daily work, dress and food. Nevertheless, he is conscious of the environment and there is no clouding of consciousness. There is no deterioration in memory or intellect either.

The patient complains of headache which is ill defined and ill localized. He suffers from constipation, lack of appetite, fatigue, lack of concentration and enthusiasm. Sleep is frequently, but not always disturbed. The depressive patient suffers from poverty of ideas to such an extent that at times he complains that he has no brain and his mind has stopped functioning.

Feelings of unworthiness, failure and guilt dominate his thought process. The patient accumulates energy during the depressive period and cannot release the pent up emotion. His aggression turns inward. His thought processes are slowed down and he blames himself for his misdeeds and sins and thinks of committing suicide.

An Indian widower who was feeling extremely guilty for his unmarried daughter became pregnant, visited a psychiatrist for treatment of his depressiveness. He felt guilty for his daughter’s condition and deeply believed that it is God’s way of punishing him for his sins. Though the girl herself did not feel ashamed and went in for an abortion, her father cursed himself for his bad ‘Karma’.

2. Acute depression:

It is more severe than simple depression. Physical, motor and mental retardations are acute, compared to simple depression. There is sharp decrease in psychomotor activity. Interpersonal relationship deteriorates as the patient avoids this. The feelings of loneliness, guilt’s and gloom are highly aggravated. He finds no solution to his problems. Thoughts of suicide are very frequent. He feels very restless and sleep is disturbed.

The acute depressive patient in other words, develops an attitude of great misery and dejection. He accuses himself of committing the most unforgivable sin and of bringing misfortune on others. Hypochondriacally ideas are frequently expressed. Occasionally hallucinations, illusions and delusions are present.

Bleuler has stated that the depressive delusions of such patients usually concern themselves with conscience. He draws a difference between the depressive delusions and hypochondriac delusions in viewing that in depressive delusion the patient worries about the future while in hypochondriacally delusion, he worries about the present.

An old widow tried a number of times to jump from the terrace of her building, but she could not gather courage to do so. A few times she was prevented by others while she was attempting suicide In spite of shock treatment her depression used to reoccur. One day however, she gathered sufficient courage and ended up her life by taking poison.

3. Depressive stupur:

It is a state of intense psychic inhibition during which regression may occur to an infantile if not primitive level. Complete inactivity and unresponsive to people or environment are the most significant characteristics of a depressive stupur which differentiates him from simple and acute depressive type.

In majority of cases considerable dulling of consciousness occurs. He is more often than not bed ridden and totally indifferent about the happenings around him. He goes to the stuporous stage, refuses to eat and speak. He is extremely uncooperative. By and large, negativism is the most significant characteristic of this stage.

The patient requires great attention in every respect. Even he is unconcerned about his bowel and bladder functions. He has to be tube fed and have his eliminative processes taken care of. Confusion regarding time, place and person colours his behaviour and hallucinations and delusions are vivid, specially about fantasies, death, rebirth and sin. At times, abstract thinking are present. The idea of death is believed by some to be most universal in stupur reactions.

The depressive stupur thus needs hospitalization for intravenous feeding, care and catheterisation. The patient requires great attention and care in every respect. A middle aged patient was admitted to hospital for severe depression. After receiving ECT he recovered to some extent. One day he asked the doctor to call his sister. As the doctor did not have her address, he said that she would come during the visiting hours.

However, when the doctor reached the ground floor of the hospital building, he heard that the patient had just jumped from the bathroom window.

Etiology of unipolar depression:

Biological:

It has been reported that there is decreased Himipramine binding to blood platelets from some depressed individuals. Large numbers of studies have reported various abnormalities in bionic amine metabolites in blood, urine and cerebrospinal fluid in mood disorder patients. Abnormalities of the limbic-hypothalamic-pituitary-adrenal (CHPA) atis are the most consistently reported neuro endocrine-dysregularities.

Findings indicate that hyper secretion of Cortisol is present in some depressed patients. The DST (Dexamethasone suppressed test) is abnormal in about 50 per cent of the depressed patients indicating hyperactivity of LHPA axis. Other neuro endocrine causes of depression include hypo (less) release of thyroid stimulating hormone upon administration of thyroid releasing hormone.

Depressive patients usually do not have a good sleep and sleep irregularity is very often found in them. This is perhaps the most important proof that depression has a biological cause. Frequently of early morning awakening and discontinuity of sleep increases in depressed patients. Multiple awakening during night also increases. It has also been remarked that depression is a disorder of chrono-biological regulation.

It can therefore be concluded that unipolar disorder involves pathology of the limbic system, the basal ganglia and the hypothalamus. Studies further indicate that neurologic disorders of the basal ganglia and limbic system are likely to present with depressive symptoms.

The stopped posture, motor stowness and minor motor cognitive impairment seen in depression are quite similar to disorders of the basal ganglia like Parkinson’s disease and other subcortical dimensions.

Personality factors:

Though all persons with different type of personality pattern can have depression under appropriate circumstances, certain personality types like oral- dependent type, obsessive compulsive type, hysterical may have greater risk for depression.

The antisocial, paranoid and other personality type who use projection and other externalising defence mechanisms for channelising their emotion etc. have relatively less depression.

Psjxhoanalysic factors:

According to Freud’s structural theory, the ambivalent introjecting of the lost object into the ego leads to depressive symptoms.

Learned helplessness:

When the organism learns that he is helpless, it leads to depressive symptoms. Depression can be reduced if the psychiatrist creates a sense of control and mastery to reduce helplessness in the patient. Reward, positive reinforcement and a sense of success created by some sort of achievement can help in the matter.

Avoidance of negative distortions of life experience, negative self evaluation, pessimism and hopelessness will obviously develop a positive attitude towards life and would help in reducing depression.

Treatment:

Mild depression may be treated in the office of the physician, at home or as an outpatient provided the symptoms are at a minimum level. The support system should also be quite strong to avoid hospitalisation. But in case of severe depression hospitalisation is a must.

Approximately 50 per cent of the patients have their first attack of depression before 40 years of age.

Acute depression can be treated through drugs. However applying drug on the depressive patient it must be ensured that:

(1) The depression is a combination of biological and psychological factors,

(2) That the patient will not get addicted to anti-depressants since these drugs do not give immediate relief,

(3) The patient should be explained that the drug will have slow effect and also side effects,

(4) The patient must also be informed that sleep or appetite will improve first and the feeling of the depression will change. Further taking into consideration the past history of the patient anti-depressants may be prescribed. Although controversial E.C.T. (Electro Convulsive Therapy) is perhaps the most effective treatment, antidepressant treatment so far particularly for depression has quick effect.

Psychotherapy:

Antidepressants combined with Psychotherapy bring better results than either method alone. Interpersonal behaviour, individual Psychotherapy, family therapy and cognitive therapies bring good results in the treatment of depressive patients.

It is found that individual Psychotherapy helps the patients to be more aware of their moods and the results of their acts on others in the environment.

3. Circular type:

The circular or mixed type is also known as the alternative type where elation and depression occur alternatively. It is also called bipolar type of manic depressive psychoses. In this type, the manic and depressive types are combined into a single category. About 15 to 25 per cent of the manic depressive reactions actually indicate an alteration between manic and depressive symptoms.

According to Coleman (1981) although many believe that these mood swings of manic depressive state are common, in fact, about one out of 5 manic depressive people suffers from this circular variety. An unusual case of a manic-depressive patient has been quoted by Jenner, et al.( 1967), whose manic phase lasted for 24 hours and was then followed by a depressed stage which also continued for 24 hours. This cycle continued for 11 years.

Bunney, Murphy, Goodwin and Borge (1972) have also cited the case of a woman patient who shifted between mania and depression every 48 hours for a period of 2 years. Such cases are not common though. The patient in the circular type thus experiences mania and depression in a cyclic order. There even may be a gap of normality when the patient shows normal behaviour. This is suddenly followed by a second attack when the patient may experience severe elation and excessive happiness. Interestingly, in some other cases the patient may go to sleep with depression and get up with manic episode.

In the circular types, at first there is mild depression with subjective uncertainty, slight restlessness, and mild elation over successful work, then depression again of greater duration followed by elation.

Elation periods are characterised by aggressiveness, frequent irritability and pronounced erotic tendencies. During the depressive period, there is intense depression with suicide attempts. The patient may lie on the bed, immobile. A dull depressed expression may be marked on his face.

A middle aged man made a lot of fortune during the manic period. He was over active and very enthusiastic. He would be talking and talking all the while. Sometimes he would dress himself in the funniest manner. At times, he would put on a garland and go to the doctor’s clinic. However, when depressed, he never comes out of his house. He felt like ending his life, but could not gather the courage to lift the phone to call the doctor for advice.

Kraepelin (1937) has described the mixed state as a combination of manic and depressive state. He differentiated 6 principal types.

1. Maniacal stupur

2. Agitated depression

3. Unproductive mania

4. Depressive mania

5. Depression with flight of ideas

6. A kinetic mania.

According to Kraepelin these conditions not only occur singly in the course of either an acute excitement or an acute depression, but as transition stages during the changes from excitement to depression. The essential picture of the mixed state is an elated mood with restlessness, alertness and talkativeness. Then it shifts to a state of distress and depression accompanied by mutism. At the beginning of the attack, the association of mutism with a slightly happy smiling mood and free movements constituted a fairly typical example of the mixed state.

The physical symptoms of the mixed state are as follows:

1. Disorder of sleep

2. Loss of appetite.

Controls of these two factors are the key stone of treatment particularly in the acute phase. The manic patient is so restless, so distractible and so busy that he has no time either to sleep or to eat, whereas the depressive patient, is so tormented by upsetting ideas and feels so unworthy that he does not consider himself entitled to any food that is offered to him.

It has been observed that practically most depressive cases have a high blood pressure while in the maniac, the blood pressure is reduced. But this has not been confirmed by scientific findings.

The findings of a clinical study conducted on the patients of a Metabolic research ward at the National Institute of Mental Health, Bethesda, Maryland, by a group of investigators led to the anticipation that a biological switch mechanism may be factor in sudden cyclic shifts from depression to mania.

With the assumption that “something must be happening in the body as well as the mind” of such patients, the above investigators studied biochemical changes in six manic-depressive patients, who with one exception were not on medication.

A brief but marked elevation in a biogenic amine in the urine of the depressed patients on the day of the switch was noted. Patients with the most rapid onset of mania also showed the most marked elevation in this biogenic amine on the switch day.

The investigators also presumed the role of identifiable environmental stresses played a part. However, they were not able to recognize such stresses in the change out of mania. This impression was supported in an additional study of patients switching from mania into depression as well as depression to mania.

Manic Depressive Disorders in Childhood:

In spite of the fact, that affective psychosis is very uncommon in young children, Kraepelin (1896) noted that within the age range of 15—20 years, the first attack of M.D.P. may occur. He also noted that such cases are rarely found in children less than 13 years age.

On the other hand, Winokur and associates had a haunch to find out if M.D.P. is found in children as young as 10 years age and strangely, they got a positive proof of this. They have cited a case named Mary, W; 12 years old who had her first attack at the age of 10 years.

The depression which started at the first stage continued for 7 months after which the manic stage appeared and she became highly elated, talked excessively and had flight of ideas. This was followed by a depressive stage for 2 weeks and then it switched on to manic stage for 4 months alternatively.

This case typically seemed to be one of manic depressive psychoses which started before puberty.

Explanations of manic-depressive disorders

Biological factors:

The need for a biological explanation of manic-depressive psychoses arises from the fact that once the disorder is in the process, it continues automatically and completes the full course unless otherwise controlled by drugs and other medicines. The biological factors of manic-depressive psychoses include hereditary, constitutional, neurophysiologic and biochemical factors.

(a) Hereditary explanation:

In a study of M.D.P. patients Slater (1944) noted that in about 15 per cent of the cases, brothers and sisters, parents and children of manic-depressive patients also suffered from M.D.P. Rich et al. (1969) confirmed the hereditary explanation when they found that 20 per cent of the mothers of 347 cases suffer from M.D.P. Thus they concluded that children from M.D.P. parents have normally higher probability for M.D.P., than only the fathers suffering from M.D.P. Kallman (1958) in his study of identical twins found when one twin suffered from M.D.P., the other also suffered.

Kraepelin pointed out that 0 to 80% of the cases of M.D.P. can be attributed to hereditary disposition: The advocates of hereditary explanation viewed that M.D.P. is transmitted from parents to the off springs through a single dominant gene transmission.

In all these studies, however the effects of early environment and learning have not been controlled. So it would be just erroneous to conclude that M.D.P. is due to the hereditary predisposition alone. Thus, Coleman (1981) concludes, ‘The precise role of heredity is far from clear, although it seems realistic to consider it an important interactional factor in the total picture.”

(b) Constitutional explanation:

Kretehmer viewed that picnic type of personality generally suffer from M.D.P. He categorized the short, bulky people with thick neck and broad face as having picnic type of personality. According to Meyer, Hock, Kinby, Bluler and others, psychesthenic people characterised by moods, swinging from elation to depression generally suffer from M.D.P. They may be quite brilliant, talkative and aggressive people who may take the affairs of life ordinarily or who may have a gloomy outlook towards life and take little matters quite seriously.

(c) Neurophysiological explanation:

Certain earlier investigators reveal that manic reaction is a state of excessive excitation and weakened inhibition of the higher brain centre and depressive reactions occur due to excessive inhibitions. The interest in the area developed by the work of Pavlov led to the possibility of the fact that imbalance in the excitatory and inhibitory processes may predispose some people towards change of moods such as mania and depression.

According to Engel (1962) the central nervous system is apparently organised to mediate two opposite patterns of responses to mounting needs, the first is an active goal oriented pattern directed towards gratification of needs from external sources. The second is a defensive pattern aimed at reducing activity and thereby increasing the barriers against stimulation and conserving the energies.

Manic reaction seems to be an exaggerated form of the first response pattern, while the second response pattern may be attached to depression. So motor retardation of the depressive and psychomotor activities of the manic do suggest polar opposites in neural functioning.

Biochemical factor:

Metabolic disorders of the catecolamine are well proved in the M.D.P. It has been found that abnormality in indocolamine metabolism is related to depression. Schildkrant (1970) viewed that depression may be associated with a deficiency in brain norepinephrine and the manic behaviour shows an excess of norepinephrine.

In support of his theory he argued that psychoactive drugs which increase mood tend to produce an increase in norepinephrine at synapses, but those which produce depressed mood cause a reduction of this biochemical.

When the neurotransmitter substance is of appropriate amount, it allows normal neural transmission. But when it exceeds the normal level, the nerves are excited too frequently leading to manic stage. On the contrary, it is below the normal level, the neurons are unable to respond to the normal impulses resulting in depression and inactivity.

Duke and Nowicki (1979) report that “Research on antidepressant medications and their mode of action contributed much support to the catecolamine hypotheses. Different types of antidepressant drugs work in different ways to affect the presence of norepinephrine. For example, a group of antidepressant drugs called monamine-oxidase (MAO) inhibitors check the actions of the enzyme that metabolizes norepinephrine, thereby elevating the concentration of this neurotransmitter at the synapses.

It is further pointed out that lithium carbonate, a currently widely used drug in the treatment of manic depressive psychoses reduces the flow of norepinephrine at brain synapses and this in turn decreases the hyper responsively of the nervous system and slow down neurotransmission to a relatively normal level.

It is true though, that the information about the function of neurotransmitters is based on animal research, some studies on mental patients have also confirmed the above facts. Kety (1975, a) found high levels of norepinephrine in the urine of manic patients and low level in depressive patients.

Subsequent investigations conducted by Maas, Fawability and Dekirmenjian (1972) have proved that with successful treatment of antidepressants there is increase in the level of catecolamine in depressive patients and this finally brings them back to the normal condition.

Inspite of the empirical findings in support of the biochemical explanation, M.D.P. and particularly neurotransmitter variations as the cause of M.D.P., the biochemical explanation only proves that the neurotransmitter variations exist, but it is not able to explain the cause of neurotransmitter variations in M.D.P. patients.

Duke and Nowicki also opine that the catecolamine hypotheses by itself does not seem to explain adequately the biochemistry of affective psychoses.

Research has also highlighted the fact that deficiency in indoleamine metabolism is related to depression. But at the same time, serotonin levels have also been found in lower degree than normal in manic patients as in psychotic depression. The presence of lower amount of serotonin in both manic and depressive patients makes this explanation very complicated and confusing.

However, Kety (1975, a) states that “a deficiency of serotonin at central synapses is an important genetic or constitutional requirement for affective disorder, permitting what might otherwise be normal and adaptive changes in norepinephrine activity and the resultant mood states to exceed the homeostatic bounds and progress in an un-dampened fashion to depression or excessive elation.”

Duke thus concludes “Thus variations in mood in affective psychoses would be attributable specifically to norepinephrine variation, but the predisposition to over action in the form of extreme variation would be the result of a genetic lack of the dampening effects of serotonin. This intriguing hypothesis is yet to be tested fully enough to make suitable evaluation possible.”

Psychological explanation:

Freud and other psychoanalysts have attempted to give a psychological explanation of manic depressive psychoses. Currently, learning theorists have tried to explain the causes of affective psychoses through life experience, learning and various other psychological events.

Psychoanalyst, Karl Abraham (1948) was of opinion that ambivalent, ego centric people are more prone to affective psychoses. They in fact are incapable of expressing one feeling in the absence of another. They are unable to express pure love which leads to feelings of pure impoverishment. How this impoverished feeling arises? It is the function of fixation at the oral stage of psychosexual development; caused by an ambivalent attitude towards the mother. The person fixated at the oral stage develops the tendency to be terrifically dependent upon other people.

In the opinion of Duke and Nowicki (1979) “Such people grow up being unable to relate adequately to love objects and experience intense frustration while trying to obtain gratification from them.

In reaction to problems in relating to others, in later life they regress to the oral level and relate to themselves with the same love hate ambivalence. Sometimes they hate themselves (depression) and sometimes they love themselves (Mania).”

Freud viewed that the behaviour of grieving was similar to that of depression. He viewed that depressed people mourn the loss of their own – egos just as distressed people mourn the loss of their near and dear ones.

The ego of the patient has already strongly, identified with the loved object itself 3 and when the loved person is lost or the individual looses the love of his most beloved, he strongly feels the loss and this leads to depression. He also experiences guilt of real and imagined sins against the person lost.

Freud further opined that depression represented a turning inward of aggressive feelings that may have been felt toward another person. People, who are unable to channclise their aggression in proper ways, experience a deep sense of despair and it may lead to suicide since the aggression turns inward. To add to this, Kendal also found that in societies where aggression is permitted, there is a lower incidence of depression.

According to Meyer (1948) Manic depressive psychoses is a reaction to stressful condition involving both biological and psychological components which serve both as defective and compensatory nature. Such reactions are accepted as protective mechanism to protect the individual or relax the stress to bring about recovery. Areiti (1969) reviewing a large number of studies concluded that reaction pattern to stress may be classified into 3 types.

1. Death of a loved one.

2. Failure in interpersonal relationship.

3. A severe disappointment or set back in work to which an individual has devoted his life. All these precipitating conditions involve loss of something that has great value for the individual.

Manic reactions are in fact responses to escape one’s difficulties by flights to reality. There are evidences to show that in severe stress situations the individual attends more parties and tries to forget the broken love affair, or tries to escape anxiety by being overactive and over busy. Thus, hyperactivity is found in the manic patient.

Several ego analysts like Jacobson (1953) have found the key cause of depressive psychoses in the loss of self-esteem. Jacobson thus writes “Manic depressive manifests a particular kind of infantile narcissistic dependency on their love object.

What they require is a constant supply of love and moral support from a highly valued love object, which need not be a person, but may be represented by a powerful symbol, a religious, a political or scientific causes or an organisation……………….. as long as their belief in this object lasts they will be able to work with enthusiasm and efficiency. Such people, according to Jacobson underestimate their loved object.

When the loved object is lost or threatened depression associated with low self image of the undervalued ego occurs. A normal individual when depressed takes recourse to constructive activities designed to reduce the threat to self esteem. Either one may lower his level of aspiration or through the use of some defences he may try to change his perceptual to events. But the depressed person instead of taking recourse to constructive activities or adjusting his goals, a feeling to helplessness and depression occurs.

On the other hand, the manic reactions are the results of excitement around the belief that the unrealistic goals are being solved, though they are not solved in reality.

The role of environment and family has also been emphasised in predisposing an individual to depression. By setting examples and models through one’s own actions the children may directly be motivated to show similar type of behaviour. About 80 per cent of these cases have been reported having adverse life events precipitating this pathological condition.

Studies on depression:

According to Beck (1967) there is a positive relationship between feelings of guilt, shame and unworthiness over past work and depression. But similar findings are not found in the patients of non-western culture as reported by Venkoba Rao (1973) who reviewed the studies on the depressive patients in Africa, Japan, Philippine, Iraq and China, Bangladesh and Pakistan. Among the Indians, he said, the Hindus showed less shame and guilt.

Venkaba Rao further states that the incidence of depression has been found to have decreased in the U.S.A. In U.K. and Canada, marginal increase has been reported on the basis of hospital admission, the prevalence of all forms of depressions found to be 3% while it is 12% in India.

He further reports that the incidence of depressive psychoses is relatively higher in North India in comparison to South India perhaps because of the rituals in South India.

Treatment:

Hospitalisation:

A manic or depressed person may need hospitalisation when there is risk to his own self or others when the family environment is disturbing for the patient or when a need for shock treatment is required. Also the need for hospitalisation occurs when the patient does not take food for days together and needs to be tube fed.

Currently, use of antidepressant drugs have however, reduced the need for hospitalisation. But in severe cases hospitalisation cannot be avoided. Hospital further provides better physical care to the patient, removes disturbing home influence, acts as a protective measure against suicide and other responsible behaviours.

Physical rest:

Some patient also gains by sleep than by sleep therapy. Rest in some cases seems to be the best medicine for every type of mental disease.

Psycho chemotherapy:

Wide application of chemical treatment for depressive and manic patient has greatly reduced the percentage of admission in hospitals. Antidepressant drugs such as inipramine are generally used for the treatment of depressive patients. Proper dosage is determined through trial and error adjustment. Use of electric shock in M.D.P. patients has decreased due to the wide application of antidepressants.

Through antidepressant drugs also uncooperative patients have become more responsive to psychotherapy. Drugs for depression have been available since 1950s. But only in the 1970s lithium carbonate has been used effectively for treating manic patients and to prevent their occurrence. As a rule, lithium carbonate must be administered under careful medical supervision.

Electro convulsive shock therapy:

ECT is extremely effective in treating severely depressed patients. It however has better effect on manic symptoms. Many psychiatrists are of opinion that it is better to begin ECT than to wait for antidepressant drugs to be effective. In the absence of any specific form of treatment, time acts as the great healing agent and the disease runs its course and terminates within a few months.

However, successful treatment of mental disease depends to a great extent upon the personality make up and experience of the psychiatrist. In India there is very little provision for dealing with such cases. In future, therefore efforts should be made for the successful treatment of the M.DP. Patients not in urban areas alone but also in the rural section of the country.